Medication errors in hospitalized pediatric patients can lead to significant patient harm, as well as increased health care-associated costs and longer length of stay. Technology and automated systems can be utilized to prevent errors and provide an additional layer of protection for these vulnerable patients. Consider the value of bedside bar code medication administration (BCMA) in reducing errors associated with medication administration. The American Society of Health-System Pharmacists (ASHP) supports the expansion of bar coding technology across the spectrum of medication preparation and dispensing to ensure that products are correct, in-date, and have not been recalled.1 Bar code scanning is recommended when manually packaging oral and liquid medications; during compounding, repackaging, and labeling of products; and for dispensing from pharmacy to any location.
Despite the safety that BCMA delivers, significant gaps in error prevention still exist, particularly for pediatric patients. For example, when pediatric patients receive oral liquids in patient-specific syringes, the effectiveness of BCMA is contingent on the accuracy of the pharmacy-prepared syringe, as well as correct validation of the administration volume and route. In the case of non-standard, ready-to-use, patient-specific doses, BCMA can only confirm that the right patient is receiving what presumably is the right medication, dose, and route, at the right time. For these reasons, additional automation and technology solutions, including IV workflow software, are needed to assist in closing these safety gaps.
Published reports illustrate the benefits of adopting IV workflow management systems that incorporate bar code technology and integrate with pharmacy information systems.2,3 These workflow systems promote visibility throughout the preparation and dispensing process of IV medications, improving medication safety, streamlining pharmacy workflow and productivity, and reducing waste.
The University of Florida Health Shands is an 1111-bed, tertiary medication center that includes a 207-bed pediatric hospital. The hospital is currently evaluating IV workflow software systems in an effort to reduce compounding errors, standardize workflow processes, and streamline workload with remote order verification capabilities. Electronic documentation of the preparation and dispensing processes for quality control and tracking purposes are additional features driving the investigation of these systems.
Ensuring that the correct product is prepared and dispensed before the medication reaches the bedside is critical to error prevention. Pediatric medication preparation is particularly vulnerable to errors, given that many medications are prepared as patient-specific doses, are based on weight or body surface area, and require compounding or manipulation of commercially available products into concentrations appropriate for use. Common preparation errors include use of expired product, and choice of incorrect drug, concentration, or dispense volume.4 IV workflow systems can improve medication safety during preparation by capturing expired products, ensuring correct product selection (drug and concentration), and preventing overall preparation errors.
An area of vulnerability for IV workflow management systems is the inability to detect final volume errors. Visual inspection by the pharmacist remains the last step prior to dispensing that may catch this particular error.
While preventing errors at the point of administration is an important part of medication safety, it is also the last step in the process. Medication administration errors are particularly prevalent in pediatric patients, accounting for a mean of 50% of all reported medication error reports.5 Medication administration errors typically result from incorrect preparation and doses, as well as wrong infusion rates and incorrect timing of administration.5 While incorrect infusion rates and timing of administration errors may be prevented via BCMA and smart IV pump technology, respectively, these technologies cannot necessarily identify incorrect preparations and doses.
Assuring that the medication is correct well before it reaches the bedside is critical to error prevention. As such, forced functions may be an effective method for pharmacy to reduce medication dispensing errors. Implementation of technology that requires the correct completion of stepwise functions to complete the medication preparation process, such as IV workflow software systems, may prove beneficial.
Benefits of Implementing IV Workflow Management Systems
When considering an IV workflow management system implementation, the most critical benefits include improvements in pharmacy operational efficiency, medication safety, and waste reduction.
Key points in the workflow process include the capability of the workflow management system to communicate in real-time with the institution’s computerized prescriber order entry (CPOE) system, the ability of the pharmacist to verify medications remotely, the availability of live tracking of orders during the dispensing process, and the capacity to easily locate products after dispensing.
The workflow management system’s ability to interface with the CPOE system is paramount to its potential to improve efficiency. Minimizing the number of manual manipulations or input needed between systems helps optimize safety and efficiency. When the IV workflow software system interacts in real-time with the CPOE system, orders can be automatically removed from the preparation queue when they are discontinued or changed. Utilizing status boards that reflect the current work orders being prepared and those awaiting preparation allows for a quick visual verification of where specific medication orders are in the dispensing process.
The capacity for pharmacists to remotely verify compounded or patient-specific medication doses is another feature that can significantly streamline pharmacy operations. IV workflow systems capture images throughout the medication preparation process to verify against the finished product. Pharmacists do not need to be present in the cleanroom as they can ensure that medications are prepared correctly from any location with digital access to the workflow system. In departments with limited staffing resources, remote verification helps increase product verification coverage.
Real-time tracking of the product after dispensing is another notable benefit of utilizing an IV workflow software system. A single bar code is generated for the medication label after final product checking, so verified doses can be scanned during later steps in the delivery process. Thus, an audit trail is created to track and view the order status from the point of order preparation throughout the delivery process. This audit trail can streamline workflow when technicians and pharmacists receive questions from nursing staff regarding medication order status.
An example IV workflow preparation and dispensing process is described in FIGURE.
Data supports the benefits of IV workflow management systems on error reduction in pediatric hospitals.2,4 Organizations that have implemented IV workflow software have improved the quality of patient care, reduced error rates, and optimized medication use (see SIDEBAR).2
Implementing IV workflow software may also impact medication waste. Medication doses that are discontinued after entering the preparation queue are automatically removed, preventing technician preparation, pharmacist verification, and inappropriate dispensing. Cost avoidance can be determined by applying the average cost per medication for those that would have been filled after order discontinuation, and for those that would have been inappropriately filled based on wrong dose pulled for preparation but stopped by bar coding technology. In one study, total cost avoidance for an 8-month period was nearly $470,000; IV medications comprised about 60% of these savings.2 The combined impact of workflow management systems on personnel efficiency and drug cost avoidance are likely even greater than these numbers suggest, because the reduction in the total number of doses prepared and verified also creates savings in drug costs and labor use.
Potential Barriers to IV Workflow Software Implementation
The significant investment in terms of budget and training is likely the most common barrier to widespread implementation of pharmacy workflow management systems.3 Costs must be evaluated to determine if implementation is in line with the organization’s fiscal goals. However, be sure to balance the medication safety and productivity benefits against factors such as the expected return on investment, annual maintenance costs, cost of staff training and potential compensation for increased skill sets, and construction/remodeling fees.
Extensive staff training and education sessions are critical to successful implementation and utilization of IV workflow management systems. Sufficient training will increase staff buy-in and reinforce the safety benefits of the software. While the software may require an increased time commitment initially, preparation times will decrease with time.
Other potential implementation challenges include the robust project management requirements, vendor assessments, and the ability to integrate the system with all existing information systems and technology.3 Assigning key personnel to create a plan for project development will help to determine an appropriate implementation strategy. Networking with other institutions will prove beneficial in selecting software and in overcoming implementation challenges. Ensuring that the IV workflow management system interfaces with existing order entry systems is vital to accessing full functionality of the technology.
Preparation errors are all too common in pediatric medications, and relying on technology to capture these errors at the point of administration is not a sufficient prevention strategy. With IV workflow management systems, pharmacists can utilize technology to prevent or reduce preparation-related medication errors, improve staff workflow, and limit unnecessary drug waste.
Keliana L. O’Mara, PharmD, is the NICU clinical specialist at the University of Florida Health Shands in Gainsville. In addition, Keliana is a co-residency program director of the pediatric pharmacy residency and coordinator of the pharmacy residency research committee. She received her PharmD from the University of North Carolina School of Pharmacy in 2007 and completed a PGY1 at Moses Cone Health System followed by a 2-year neonatal pharmacotherapy research fellowship at Women’s Hospital of Greensboro. Keliana’s professional interests include neonatal pain management, patient-specific pharmacokinetic dosing, NICU safety, and optimization of IV nutrition in premature neonates.
Studies of Error Prevention with IV Workflow Software in Pediatric Hospitals
To evaluate the effectiveness of IV workflow software, one site focused on errors that occur during oral liquid dose preparation.1 Errors were detected in approximately 2% of nearly 200,000 doses prepared over a 12-month period. Of the errors found, 86% were identified by the IV workflow system; a pharmacist identified the other 14% at the time of final product inspection. Errors identified by the IV workflow system were predominantly technological (ie, mismatch between the system’s database and the EHR database, or a drug not available in the system) and incorrect drug errors, followed by expired product and right drug/wrong concentration. Errors identified by pharmacists included incorrect final dispense volumes, preparation errors, expired products, and incorrect drug or concentration.
Note that this study did not include comparative dispensing error data prior to the IV workflow system implementation. Out of 3812 total errors detected, 30% were attributed to the incorrect drug being pulled for dispensing. Quantifying the incidence of this type of error can be difficult in the absence of bar coding scanning during preparation. Should the pharmacist fail to recognize that the wrong drug or concentration has been dispensed into a patient-specific syringe (with a patient-specific bar code) during the verification process, the BCMA system cannot detect the wrong medication prior to administration. Including bar code scanning during preparation as part of the workflow management system provides a key layer of protection to reduce wrong drug or concentration errors.
In another study, the impact of an IV workflow system implementation on oral and IV medication error reduction was evaluated.2 Over 1.5 million doses were dispensed during the 17-month study period. The post-implementation period comprised 826,220 doses over the latter 8 months and demonstrated significant error reduction. Preparation errors decreased by 1.6 errors per 10,000 doses dispensed. Per week, medication errors decreased from 2.7 to 0.4 (oral) and 0.2 (IV). Moreover, the time between reported preparation errors increased from 7 to 48 days. Of the errors reported, 16 were incorrect volumes and 4 were mislabeled product. Mislabeled products were primarily attributed to product being dispensed before the pharmacist’s final verification was complete. In addition, the system also prevented over 10,000 wrong drug preparations from occurring secondary to bar code scanning. These potential errors were equally distributed between oral and IV doses. Ultimately, this study demonstrates the value of workflow management systems not only in reducing overall medication preparation error rates, but also in expanding the number of consecutive days between errors.
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